Geriatric Depression Flashcards by Alana Meikle

what is the community prevalence rate of late life depression

11.2%

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list components of a complete assessment for late life depression

A complete assessment for late-life depression requires:

Reviewing the diagnostic criteria for late-life depression

Reviewing current medications, allergies, and substance use

Reviewing current stresses and life situation

Assessing level of functioning/disability

Considering support system, family situation, and personal strengths

Cognitive testing

Neurological exam and physical exam if applicable

Ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms (e.g. - hypothyroidism, anemia)

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what population makes up the bulk of the increased risk of completed suicides in older adults with depression

older white males

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name a scale that can be used to assess late life depression

Geriatric Depression Scale (GDS)

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what is the vascular depression hypothesis

cerebrovascular disease predisposes, precipitates, or perpetuates depressive symptoms in late life

vascular disease is thought to affect FRONTO-STRIATAL circuitry –> resulting in executive dysfunction, depression and cognitive impairment

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what is the prevalence of delirium superimposed on dementia

ranges from 22-89% of hospitalized and community populations aged 65+ with dementia

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what are the cardinal features of depression, dementia and delirium

dementia–> memory loss

delirium–> inattention and confusion

depression–> sadness, anhedonia

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compare the onset of depression, dementia and delirium

dementia–> insidious

delirium–> acute or subacute

depression–> slow

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compare the course of depression, dementia and delirium

dementia–> chronic, progressive (but stable over the course of the day)

delirium–> fluctuating, often worse at night

depression–> single or recurrent episodes, can be chronic

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compare the duration of depression, dementia and delirium

dementia–> months to years

delirium–> hours to months

depression–> weeks to years

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compare the LOC in depression, dementia and delirium

dementia–> normal in early stages

delirium–> impaired, fluctuates

depression–> normal

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compare attention in depression, dementia and delirium

dementia–> normal (except in late stages)

delirium–> poor

depression–> may be impaired

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compare presence of hallucinations in depression, dementia and delirium

dementia–> often absent

delirium–> fleeting, non-systematizes

depression–> not usually (inly if psychotic depression)

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compare EEG findings in depression, dementia and delirium

dementia–> normal or mild diffuse slowing

delirium–> moderate to severe background slowing

depression–> usually normal

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how well do ADs work to treat depression in dementia

not well–> guidelines do not suggest routine treatment of depression and anxiety with antidepressants

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what types of psychotherapy have strong evidence in late life depression

CBT

problem solving therapy

IPT

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list 4 ADs that are relatively safe in the elderly

buproprion

mirtazapine

moclobemide

venlafaxine

*lower anticholinergic effect compared to older ADs
–minimizes delirium risk and cognitive impairment risk

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in clinical studies, which ADs have been shown to be the most efficacious in the treatment of late life depression

MAOIs and TCAs

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which two TCAs have the lowest anticholinergic burden

nortriptyline

desipramine

*most tolerated of the TCAs

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what should be the “first step” in pharmacologic treatment of late life depression

monotherapy with one of the following (or in sequence):
duloxetine
mirtazapine
sertraline
venlafaxine
vortioxetine
citalopram
desvenlafaxine
escitalopram

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what should be the “second step” in pharmacologic treatment of late life depression (if multiple first step treatments are not effective or not indicated)

switch to:
nortiptyline
fluoxetine
moclobemide
paroxetine
phenelzine
quetiapine
trazodone
buproprion

or combine with:
ablify
methylphenidate
lithium

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what should be the “third step” in pharmacologic treatment of late life depression (if multiple 1st and 2nd step treatments are not effective or not indicated)

switch to amitriptyline or imipramine
or
combine an SSRI or SNRI with buproprion

how does mortality rate compare between older adults that receive ECT for depression vs other treatments

older adults who receive ECT have a LOWER mortality rate compared to other depression treatments (like antidepressants)

what combination of ECT and ADs has evidence for rapidly acting and effective treatment of late life depression

RUL ultrabrief pulse ECT (avg. 7 treatments of ECT) + venlafaxine

very good safety and tolerability when this combination is used

list psychosocial interventions that have evidence for preventing or reducing depressive symptom burden in older adults according to the CCSMH guidelines

1. interventions to reduce loneliness in older adults (i.e physical exercise programs) 2. "social prescribing"--referral to local nonclinical services often provided by voluntary or community sector 3. stepped care approach (including watchful waiting and CBT based bibliotherapy) 4. increasing physical activity 5. "instilling of hope and positive thinking" 6. tai chi/yoga and other mind-body interventions

in which older patients is ECT a first line treatment

older, depressed patients who are at high risk of poor outcomes--> those with suicidal ideation or intent, severe physical illness, or with psychotic features

in which older patients should you consider ECT

treatment of older patients with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate antidepressant trials plus psychotherapy especially if health is deteriorating due to depression

what psychotherapy may be considered in patients with cognitive impairment and executive dysfunction

problem solving therapy

name two antidepressants that the CCSMH guidelines recommend considering as first line pharmacotherapy for acute episode of MDD in older adults

sertraline or duloxetine (could also consider citalopram or escitalopram as few drug-drug interactions but this has more risk for QTc prolongation) *ideally choose a med with lowest risk of anticholinergic side effects and drug-drug interactions as well as being safe in terms of cardiac comorbidity

in which patients might a trial of rTMS be considered

older adults with unipolar depression who have failed to response to at least 1 adequate trial of AD *not in those who have failed ECT or have seizures

what is first line for treatment of depression in patients with parkinsons disease

SSRIs with SNRIs as alternative

what is first line for treatment of post stroke depression

SSRIs (regardless if stroke is ischemic or hemorrhagic) --SNRIs or mirtazapine are second line --consider methylphenidate if APATHY is significant

What is a scale that can be used instead of the geriatric depression scale (GDS) for those people with cognitive impairment

the Cornell Scale for Depression in Dementia

how should geriatric patients with minor depression of less than 4 weeks duration be managed

supportive psychotherapy or psychosocial interventions

when should pharmacotherapy be considered in geriatric patients with depression

after 4 weeks of symptoms after psychosocial interventions have been initiated can also consider evidence based psychotherapy at this time

how should mild or moderate late life depression be treated

pharmacotherapy, psychotherapy, or both

how should severe late life depression be treated

combo of antidepressants and concurrent psychotherapy

when should ECT be considered in late life depression

those with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate trials of antidepressant trials plus psychotherapy especially if health deteriorating rapidly due to depression

in which patients is ECT a first line treatment

older, depressed patients who are at high risk of poor outcomes--> suicidal, severe physical illness, psychotic features

how should an older patient with psychotic depression be managed

clinician should use clinical judgment deciding whether to try combo AD and AP first (now have placebo controlled trials reporting this is safe and effective treatment for psychotic depression) ECT should be considered after 4-8 weeks of combo therapy fails, if poorly tolerated or if patient develops severe health consequences

which patients should be referred to psychiatry services in late life

psychotic depression bipolar disorder depression with SI those with depression with comorbid substance use d/o, severe MDD and depression with comorbid dementia may also benefit from referral

is broad use of pharmacogenetic testing recommended in older adults

no those with recurrent severe side effects to multiple ADs may benefit from testing to see if CYP450 metabolism is contributing

how well to older adults respond to AD therapy compared to young adults

similar

should ADs be used the same in those with multiple comorbidities and serious illnesses

yes--> should be used when indictaed have similar efficacy rates in unwell elderly as they do in well elderly AEs in patients with multiple medical comorbidities can be minimized by careful selection of drugs that are not likely to worsen or complicate patient specific medical problems

list side effects of TCAs that are particularly worrisome for the elderly

postural hypotension/falls cardiac conduction defects anticholinergic effects (delirium, dry mouth, urinary retention, constipation)

in the elderly, how should you monitor for hyponatremia when starting an AD

screen patient for history of hypoNa before starting the med serum sodium should be done within 2-4 weeks of initiating SSRI/SNRIs

list 3 types of ADs that have lower risk of hyponatremia

TCAs bupropion mirtazapine

how should ADs be titrated in older adults

start at HALF the recommended dose for younger adults --> aim to reach an average dose within ONE MONTH if med is well tolerated at weekly reassessments

why is fluoxetine not recommended for older adults

long half lfie

why is paroxetine not recommended for older adults

higher anticholinergic risk

how long should an older adult be treated with pharmacotherapy after successful remission of their first episode of depression

at least one year (and up to 2 years) with full therapeutic dose

which older adult patients should continue AD maintenance treatment indefinitely (unless there is a contraindication)

those who have had 2 or more episodes those who have had particularly severe or difficult to treat episodes or required ECT

what is the first line for treatment of bipolar disorder in the elderly

lithium